Provider Demographics
NPI:1689819898
Name:SOUTHWEST MEDICAL CENTER SURGICAL GROUP, LLC
Entity Type:Organization
Organization Name:SOUTHWEST MEDICAL CENTER SURGICAL GROUP, LLC
Other - Org Name:LOUISIANA HEART, LUNG & VASCULAR CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICAL
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:OLIVIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7600
Mailing Address - Street 1:4212 W CONGRESS ST
Mailing Address - Street 2:SUITE 2300A
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-6765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4212 W CONGRESS ST
Practice Address - Street 2:SUITE 3200
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-6765
Practice Address - Country:US
Practice Address - Phone:337-981-1695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HTI HOSPITAL HOLDINGS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-03
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X
LA208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA6387230001Medicare PIN